We Got Results

The Texas Medical Association has long beat the drum for cutting red tape that hinders patient care, promoting transparent insurance markets, preventing unqualified health professionals from delivering care outside their expertise, and bolstering graduate medical education (GME). Those and other messages got through to lawmakers in the 2013 session of the Texas Legislature and paid off in long-sought, even precedent-setting victories.

"With a combination of hard work, good timing, and more money in the budget, we got results," TMA President Stephen L. Brotherton, MD, said, adding that medicine's success also was due in large part to seeds TMA planted early on. "We did a lot of grassroots work from the county level on up. Doctors and alliance members were talking with their local legislators back home. And we did our homework."

For instance, the first-ever "silent PPO" legislation that TMA won this session took eight years because "for a long time, those activities were difficult to sort through and understand, even for legislators. So part of what TMA had to do was make sure everybody understood what was happening," Dr. Brotherton said. "Just like when we got Proposition 12 [tort reform] passed (that was a 16- to 18-year project), we did our homework. We took it to the state. We got it accomplished. Now this [silent PPO law] will make companies negotiate in good faith and stop others from stealing physicians' discounted contract rates."

Dr. Brotherton added that TMA's victories this session are good not just for physicians. "Putting money back in GME and women's health that never should have been taken out in the first place; refunding the deductible for dual-eligible [Medicaid and Medicare] patients; and expanding vaccinations – all of that is good for everyone who lives in the state of Texas."

The 2013 session began with an unprecedented number of medicine's candidates entering the House and Senate with support from the Texas Medical Association Political Action Committee (TEXPAC), TMA's political advocacy arm, and the association's volunteer force, the TMA Alliance. It ended in numerous wins for physicians and their patients with the help of lawmakers who pushed medicine's key bills to the finish line, as well as the voices of dozens of physicians who testified at the Capitol and more than 1,000 physicians, medical students, and alliance members who lobbied in force at TMA's monthly "First Tuesdays at the Capitol" events.

Landmark regulation of third-party payers or "silent PPOs" that take physician-contracted discounts without doctors knowing about it;

A new standard for physician-led, team-based care and for future legislative scope-of-practice discussions;

Widespread reductions in practice red tape, including a streamlined process for renewing Controlled Substances Registration (CSR) permits and development of uniform prior authorization forms across payers;

Due process protections in Medicaid fraud investigations;

Increased access to immunizations;

More money for GME, mental health, and women's health; and

Preservation of tort reforms and a strong Texas Medical Board (TMB).

Even though not all of medicine's bills succeeded, no ground was lost, thanks to TMA's ongoing vigilance at the Capitol, leaders add.

Additional money to boost Medicaid physician payment rates never materialized, but the rates were not reduced. Heated debates halted compromise end-of-life legislation on which TMA collaborated with prominent pro-life and religious groups, hospitals, and disability groups. But physicians still have access to existing safe harbors under the Texas Advance Directives Act for resolving conflicts out of court without forcing them to violate their morals and professional ethics.

The end-of-life effort was undertaken by one of several coalitions TMA forged with influential state groups and lawmakers that led to compromise legislation this session and will continue to pay off in future discussions, Dr. Brotherton says.

TMA Council on Legislation Chair Leslie Secrest, MD, adds that more money in the budget also allowed lawmakers to focus attention on other issues that may at first seem small.

The ability to get a CSR permit on time, swipe patients' driver's licenses for information, and cut down on hundreds of prior authorization forms "are things that seem really simple, but when you add them up, you've just saved the profession a whole bunch of time and cost that can be put back into the delivery system."

Red Tape Reduced; "Silent PPOs" Silenced

TMA's red-tape reduction effort this session will help physician practices run more efficiently and regain valuable time and money spent away from patient care. (See "Small Problems, Big Impact," December 2012 Texas Medicine, pages 41-46.) Some of the common-sense fixes, as described by TMA leaders, breezed through the legislature, while other bills, despite some hiccups along the way, passed the final week of session.

Physician and first-time state Sen. Charles Schwertner, MD (R-Georgetown), who supported TMA's red-tape reduction and insurance transparency efforts, said those bills are "going to make the practice of medicine more efficient so physicians can focus on providing care to patients."

He sponsored Senate bills 1609 and 1610, which will streamline the standards physician practices must follow in training staff on privacy laws and for notifying patients if their private information is breached. The bills, a collective effort between TMA and the Texas Medical Liability Trust (TMLT), refine and clarify a related law passed last session. They align state training requirements with federal rules and close loopholes that threatened to subject physicians to multiple states' privacy law standards.

TMLT Executive Vice President of Governmental Relations Jill McLain says House Bill 300 passed by the 2011 legislature has strong language to protect patients' sensitive health information. But in preparing to train physicians on how to comply with it, TMLT and TMA discovered the law needed fine-tuning.

"Physicians want to follow the law, but in such a way that is reasonable and practical so that everybody achieves the intended goals," she said.

Beginning Sept. 1, physicians and their staff also can check in patients using the electronic strip on the back of their Texas driver's license, thanks to the governor's early approval of Senate Bill 166 by Sen. Robert Deuell, MD (R-Greenville), and Rep. Lyle Larson (R-San Antonio).

Backlogs in processing applications to renew CSR permits at the Department of Public Safety (DPS) are likely a thing of the past, thanks to House Bill 1803 by Rep. Bill Callegari (R-Katy) and Sen. Joan Huffman (R-Houston). Effective Jan. 1, 2014, renewal of the permits will become part of physicians' biennial online medical license renewal at TMB.

The DPS backlog was a nightmare for many physicians. One of them, Lubbock emergency physician Juan F. Fitz, MD, had his hospital privileges put on hold in March when DPS did not renew his registration on time, causing him to miss a shift.

"If you don't have your DPS license, you can't work," he said.

Fortunately, another physician – on his day off – filled in. But that's not always the case in a rural area, and without access to emergency care, "it would have been a total disaster" for patients, said Dr. Fitz, past president of the Lubbock-Crosby-Garza County Medical Society.

Putting CSR renewals on the same cycle as the medical license renewals not only will help avoid such lapses, but also will save practices like Austin Regional Clinic (ARC) the cost of dedicating a full-time staff member to keep track of the documentation and staggered renewal deadlines for its 330 physicians, says ARC Founder and Chief Executive Officer Norman Chenven, MD.

Physicians are "credentialed a thousand times over if they are working in a hospital, and it's all documented. So it just didn't make sense to create an added administrative burden and hassle," he said.

Physicians also can look forward to a day when they don't have to deal with hundreds of different prior authorization forms from multiple payers. Senate bills 644 and 1216 require the Texas Department of Insurance (TDI) to appoint stakeholder workgroups to design standardized prior authorization forms for prescription drugs and health care services, respectively, for public and private payers.

In testimony before the Senate State Affairs Committee, TMA showed that, on average, handling preauthorizations alone requires one full-time staff nurse to support every three physicians, in addition to the time spent by physicians and other staff.

Nor will physicians have to deal with surprise hassles when third-party payers or other companies and secondary networks sell, lease, or share doctors' privately contracted discounts without permission, thanks to new regulations on these silent PPOs.

Senate Bill 822 by Senator Schwertner and Rep. Craig Eiland (D-Galveston) establishes rules to identify these companies, subjects them to TDI oversight, and regulates how they share a physician's contract information, including obtaining doctors' permission to do so. The law takes effect Sept. 1.

Dr. Brotherton says these "silent PPO" practices mislead patients and cause needless, costly hassles for physicians, and the law will bring needed awareness and regulation of these activities.

"It was basically stealing," he said. "Physicians negotiated specific rates with different vendors, and through convoluted pathways, those rates were getting passed on to companies that were not making the same concessions, so doctors were not getting a fair bargain."

Dr. Secrest likened silent PPO activities to "someone subleasing your apartment without you knowing about it," adding that such practices also affect access to care.

If payers can sell physicians' network participation without their knowledge, physicians "may suddenly be responsible for thousands of patients arriving on your doorstep without being able to adjust your operations," he said. "If that's the way they are operating, how are [doctors] supposed to deliver good care without being properly staffed or without an awareness of who you are taking care of?"

The bill also won support from Blue Cross and Blue Shield of Texas. The plan's chief medical officer and TMA board trustee Dan McCoy, MD, testified that "it makes sense that providers should know who they are contracting with and what they are going to get paid."

Representative Eiland, who worked on the bill for the past four sessions, said with the new legislation, "we will be able to know what groups are out there taking doctors' discounts and where those discounts are coming from. Doctors will know exactly what the schedule for each line of business will be and who will have access to those discounts. It has been a long time coming, but I am happy to say that doctors will now have more transparency in their contracts. Transparency was a big theme this session, and I believe is one reason that this issue had more traction than in past sessions."

Senator Schwertner echoed that theme saying, "This bill is about truth in contracting and shining a light on these silent PPO networks. It's a great win for medicine to finally get this bill across the finish line," which he described as a "battle to the end" against a potential veto threat.

TMA officials praised the bill author and sponsor for getting the legislation passed, but also said TMA will continue to work with TDI and newly appointed Insurance Commissioner Julia Rathgeber as the agency develops rules to ensure that health plans treat patients and physicians fairly and appropriately.

Meanwhile, testimony by TMA physicians helped deter a swath of bills that would have required physicians to give patients up-front binding quotes of the price of their care and subject them to both financial penalties and medical board sanctions for deviating from those quotes. TMA supports transparency in health care pricing, but testified such approaches could be administratively burdensome, especially when it is impossible for physicians to predict all the medical services a patient may need, not only by that physician, but by others, as well.

Scope Compromise Wins the Day

This session also saw the usual flurry of scope-of-practice bills by allied health professionals looking to practice beyond their expertise.

Council on Legislation member and Austin neurologist Sara Austin, MD, said a shift toward team-based health care delivery models means practices like hers "are using more midlevel practitioners and physician expanders." She said the law will preserve patient safety but also "make things easier" by freeing up physicians, nurses, and PAs for patient care rather than tying them to outdated site-based rules.

TMA never deviated from the core principle that diagnosing and prescribing remain the practice of medicine, TMA Director of Legislative Affairs Dan Finch says. However, by bringing together various parties on a pre-session compromise, "what we did was change the conversation. Now we have a process and a model for future scope-of-practice discussions."

Similarly, a compromise TMA struck last session with hospital groups over employment paid dividends this year, Mr. Finch says. Whereas last session medicine contended with more than 20 hospital employment bills, this year there were two. Both adhered to the 2011 legislation that limited direct hiring to rural areas and mandated protections for physician' independent medical judgment in employment scenarios, among other provisions.

Using a similar strategy, TMA entered 2013 backing a compromise bill to help address the recurring discussions over end-of-life issues. (See "Difficult Choices," February 2013 Texas Medicine, pages 35-38.)

Dr. Austin says Senate Bill 303 aimed to address some of patients' and family members' concerns by updating the Texas Advance Directives Act to give patients more time and help with these difficult decisions, while maintaining doctors' legal rights to do what they believe is ethically and medically best for patients in their last days. Senator Deuell worked on the bill with TMA, the Texas Hospital Association, the Texas Alliance for Life, and other health care, religious, disability-rights, and right-to-life groups.

Although last-minute debates derailed the legislation, physicians still have access to the same protections that have worked for many years. The collective effort will aid in future legislative discussions on a topic that is equally difficult for physicians and patients' families, Dr. Austin says. "Doctors still can do what's right for patients. And we still have a way to resolve disagreements."

Medicaid Expansion a Bust; Progress on Reform

Meanwhile, Medicaid stole some of the spotlight this session, with the legislature ultimately declining to act on the federal government's offer of more money – as much as $100 billion over the next decade – to expand the Medicaid program. While TMA made progress on significant reforms to the program, talk of changing Medicaid coverage in any way – whether a new proposal or the one outlined by the Patient Protection and Affordable Care Act (PPACA) – went nowhere due to stiff Republican opposition.

Going down in the fight was a controversial rider tacked onto a draft version of the budget that would have allowed the Texas Health and Human Services Commission (HHSC) to negotiate certain state-based reforms with the federal government to draw down extra federal dollars. Similar legislation filed by physician and House budgeter Rep. John Zerwas, MD (R-Simonton), also failed. Among other provisions, that bill, House Bill 3791, would have expanded coverage for the working poor through private insurance coverage. Left standing, however, was a rider attached to a Medicaid managed care bill, Senate Bill 7, that explicitly requires legislative approval before HHSC or the governor can approve any waiver request to provide any coverage, Medicaid or otherwise, to currently noncovered populations in Texas.

TMA advocated throughout the session for a Texas-specific plan that would include significant reforms to the Medicaid program and that would allow the state to cover the working poor under Medicaid or a state-developed insurance coverage plan using extra federal money. (See "Fix It First," April 2013 Texas Medicine, pages 27-32.) TMA's plan, put together by the association's Physicians Medicaid Congress, included a fix-it list to repair the Medicaid program and boost physician participation through increased payments and reduced administrative complexity, as well as suggestions similar to those proposed by Representative Zerwas and others for a state-specific solution for providing coverage to the working poor using copays and deductibles and a benefits package tailored to that population, for example.

"I am saddened that Texas is throwing away $10 billion a year for 10 years because we did not address Medicaid expansion," said TMA Immediate Past President Michael E. Speer, MD, a neonatologist in Houston and cochair of the Physicians Medicaid Congress.

"TMA made some excellent recommendations on how to take care of fixing the current broken Medicaid system, and we made progress on that. But we have got to take the next step. The reality is, sick children can't go to school, and sick adults can't work," he said, pointing to research showing that health insurance coverage translates to improved health outcomes, better productivity, and lower costs down the line.

TMA Vice President for Advocacy Darren Whitehurst adds that TMA will continue to work with the legislature to find an opportunity to draw down additional federal funds to get coverage for the working poor, pointing out that the Texas Legislature's position on the issue is not unlike its early stance on CHIP before it was created in 1997.

"The legislature was not proactive then and didn't take advantage of early funding opportunities. But, eventually, financial sensibility drove the process and drove Texas to adopt a [CHIP] model that made sense. We hope to do the same for coverage of the working poor, and we will continue to push for a solution," Mr. Whitehurst said.

But he acknowledges that coverage for the uninsured was an uphill battle from the start.

Gov. Rick Perry has not let up in his staunch opposition to growing the Medicaid program with strings attached. Texas stands alongside 14 other states that oppose the PPACA expansion plan, largely because of concerns over a lack of state control and additional costs after the federal government stops paying the full tab beginning in 2017. Another six states are still weighing the option, according to the latest Kaiser Family Foundation data.

Short of a block grant that would allow states to manage their Medicaid programs on their own terms, Governor Perry and other leaders are reluctant to entertain options for offering Medicaid coverage to low-income populations not currently covered. The federal government, meanwhile, has indicated block grants are off the table.

Senator Nelson said the amendment approved by the legislature "clarifies that the provisions of SB 7 do not authorize expansion of Medicaid to low-income adults without legislative approval. We have made great strides in making the program run more efficiently, but there are limits to what we can accomplish without federal flexibility. The federal government needs to give us the tools we need, such as copays, flexible benefit options, and private market solutions to create a Medicaid system that is right for Texas."

Representative Zerwas says his proposal would have opened the door to those kinds of options, but even use of the term "expansion" became what he described as "so politically radioactive" that it halted any discussions on the matter.

"I was disappointed because I would have liked to see come to the floor for debate and ultimately to a vote what I thought was one of the headline issues for the legislative session, and one that we have largely not had any significant debate on," he said.

However, the last-minute amendment to SB 7 leaves Texas no worse off than where it started, he says. Although unlikely, nothing in the bill precludes the governor or state HHSC commissioner from initiating conversations with the federal government, and the legislature still would have a say in any agreement reached.

Expansion talks were scuttled, but that didn't stop TMA from making headway on the kind of changes physicians say are critical to attracting doctors back to the ailing program.

One significant step in that direction was Senate Bill 1803 by Senator Huffman and Representative Kolkhorst, which improves due process and expediency when a physician is accused of Medicaid fraud or overpayments. (See "Fighting for Fairness.") The bill tamps down controversial HHSC regulations released in 2012 by clarifying the definition of a "credible allegation of fraud" and establishing timelines for the Office of Inspector General (OIG) to notify doctors of an investigation and payment holds in the process.

TMA Associate Director for Advocacy Michelle Romero says the bill represents improvements over the original rules but does not go far enough to give physicians adequate due process and transparency in the OIG's process. The good news, she says, is HHSC and some legislative committees committed to oversee and report back on the Medicaid fraud investigative process, and OIG has offered to work with TMA on other fixes through the rulemaking process.

"If anything, this [session] did shine a light on the lack of due process, and we have champions [in the legislature] and hope to get better rulemaking in the interim," Ms. Romero said.

Other Medicaid reforms were included in Senate Bill 1150 by Sen. Juan "Chuy" Hinojosa (D-McAllen), a Medicaid HMO prompt-pay law that requires HHSC to include a "provider protection plan" in its Medicaid HMO contracts to ensure plans pay claims properly and promptly or face penalties. TMA leaders say such safeguards are especially important as lawmakers continue to eye Medicaid managed care expansions to generate savings. SB 7, for example, expands Medicaid HMOs to people with intellectual and development disabilities and nursing home residents, among other provisions.

Medicaid physician payment rates overall went untouched, as lawmakers grappled with adequately funding the program and its increasing caseloads. At the same time, the legislature authorized roughly $23 million in state spending to increase the premiums the state pays to Medicaid HMOs.

In an April letter, Dr. Speer informed state budgeteers of the TMA Medicaid Congress' findings that "grossly inadequate payment was the single overriding reason physicians cited for why they or their colleagues limit or no longer participate in Medicaid." He also decried the legislature's decision to authorize Medicaid managed care plans to charge higher premiums, saying "any new money [should] be dedicated to improving patient care and the availability of that care."

Senator Nelson said she "would have liked to improve reimbursement rates for our health care providers, but that unfortunately did not have the necessary support to make it into the budget."

As for the raise in Medicaid managed care premiums, Representative Zerwas said the legislature underfunded some of the managed care plans when it rolled them out into the Rio Grande Valley and some rural areas last year, "and that was merely due to the fact we didn't have the experience in those places in order to adequately compensate them for the care they were taking on."

He added that he and other lawmakers are working on accountability measures to make sure access and quality of care aren't compromised as Medicaid managed care continues to roll out.

A Better Budget

Lawmakers really have only one required task each session, and that's to pass a state budget. Coming off of a grueling 2011 legislative session that started with a $26 billion deficit and ended in deep reductions in health care funding, it seemed there was only room for improvement. Overall, the legislature answered TMA's call to reverse those cuts and avert access-to-care losses, leaders say.

With an estimated surplus of $8.8 billion and a healthy $11.8 billion Rainy Day Fund, lawmakers did not have as tight a budget to deal with as in the previous session and got down to business drafting a spending plan earlier than usual. Even though legislators still took every remaining day of the session to finalize it, medicine emerged with reparations to many of last session's harsh cuts amid competing interests to increase funding for education, water, and infrastructure needs.

The governor and state comptroller signed off on Senate Bill 1 by Sen. Tommy Williams (R-The Woodlands) and Rep. Jim Pitts (R-Waxahachie), which spends roughly $197 billion in state and federal funding for the 2014-15 biennium, a $25 billion increase over 2012-13 funding levels. The bill adds $2 billion over last session for health and human services, includes increased spending for mental health and women's health services, and takes steps to restore some of the GME funding lost last session.

Senator Nelson, who served on the House-Senate conference committee that finalized the budget, hailed this session as "very successful" in terms of meeting the state's health care needs.

The higher revenue enabled lawmakers "to not only meet our responsibilities to the most vulnerable among us, but also invest in prevention and other efforts to ensure the health of our citizens." To maintain those goals, Senator Nelson said she also "focused on finding ways to deliver services more efficiently and in a way that achieves healthy outcomes for patients" through improvements to Medicaid managed care and fraud mitigation efforts, for example.

Representative Zerwas, who also served on the budget conference committee, called the 2011 and 2013 legislative sessions as different as night and day.

"When you go through a budget-cutting session like last time, you really go after those things that don't require you to sacrifice a federal match, and women's health and mental health are two areas where we don't always have federal matching dollars available. But we really were able to put more money back into those places this time," he said. Lawmakers also intentionally shortchanged the Medicaid program by about $4.5 billion last session, "so that was one clear, urgent health care need that had to be met," and the new budget funds Medicaid "at a much more appropriate level." (Legislators did make up the $4.5 billion shortfall with an emergency appropriations bill passed early in the session.)

As part of the Texas Women's Healthcare Coalition, TMA advocated for improvements to women's health services. The program saw important gains that made up for drastic cuts during last session's budget crunch and a loss of more than $30 million in annual federal funding after the 2011 legislature voted to exclude Planned Parenthood from the former state-federal Women's Health Program. Texas has since replaced it with the state-only Texas Women's Health Program (TWHP).

Women's health funding came together through several funding streams. In addition to restoring and increasing by $32 million state federal family planning funding that the Department of State Health Services lost in 2011, SB 1 allocates $100 million more for preventive care under the Community Primary Care Services Program and for women's health and family planning services. Lawmakers also fully funded TWHP with $71 million in state funding.

Mental health services funding saw one of the largest increases in recent history with more than $225 million in new money targeting a wide array of initiatives to address Texas' mental health needs, including prevention, early identification, community-based services, and inpatient hospital care. That includes $25 million to promote private-public partnerships to improve mental health care delivery.

Dr. Secrest, a psychiatrist in Dallas, testified that for every $1 spent on mental health services, the state would see $23 returned, and as Texas' population continues to grow, the percentage of people with mental illness stays constant.

"Even in the previous legislative session, lawmakers had the sense that [mental health funding] was something they can't cut," he said. Now, the additional money, along with other mental health legislation passed this session "will help build out more robust services to address a population with mental illnesses they didn't sign up for."

Senator Nelson said the shootings in Connecticut last December shined a light on mental health, and lawmakers realized that "if left unaddressed, mental health problems present themselves in our jails, hospitals, or as we have seen recently, in tragedy."

Fighting Physician Shortages

This session also was the first in a long time in which lawmakers took a hard look at GME in Texas and its impact on ensuring an adequate physician workforce, Ms. Romero says.

GME funding overall was pieced together in the budget and through additional legislation with a $30 million, or 45-percent, raise over the last biennium. A big part of that boost came from brand new programs aimed at expanding residency slots.

Total state dollars dedicated to GME increased from $67 million in 2012-13 to $97 million for 2014-15. GME formula funding, which took a 31-percent hit last session, was partially restored in the budget with a 15.5-percent, or $8.8 million, increase over the 2012-13 biennium.

While those figures still fall short of historic funding levels – GME funding peaked at $106 million in the 2010-11 biennium – the budget includes $14.5 million in new monies to grow residency slots through new programs established in House bills 1025 and 2550.

Together, the measures create:

New one-time planning grants of $150,000 to hospitals not currently offering GME and not under Medicare GME funding caps;

Funding for accredited, unfilled, and unfunded GME positions; and

Funding for newly developed GME positions, including the potential for development of new GME programs.

TMA officials say the measures represent a greater recognition by lawmakers of the need to not only expand GME capacity, but to also offset some of the costs of training Texas' future doctors in order to keep more medical school graduates in the state.

Dr. Speer says lawmakers made some significant amends to help GME. "But this really needs to be looked at every single session, especially if we are going to increase the number of medical schools in Texas, even by one."

Senator Nelson and Representative Zerwas said that like other areas of health care, the legislature had the money this time around to enhance GME funding. They, along with other budget writers, worked on the issue before and during session, but agreed that more work needs to be done to battle workforce shortages and said lawmakers will continue to track the issue and whether the new expansion programs are keeping pace.

Lawmakers also partially restored the Family Medicine Residency Program and more than fully restored the state Physician Education Loan Repayment Program, which suffered deep cuts in the last budget cycle.

TMA also helped stop off-shore medical schools from buying up clinical clerkships in Texas hospitals and repealed a 2011 law that forced physician visa holders to spend three years working in medically underserved areas.

Big Step Forward for Public Health

Meanwhile, the Lone Star State took a "major step forward" in expanding access to immunizations, TMA Associate Director for Advocacy Troy Alexander said. In addition to these public health advances, TMA made progress in combatting childhood obesity and in escalating the cost of tobacco to prevent future use, top priorities for the Texas Public Health Coalition, of which TMA is a member. (See "Health Matters in Texas.")

Rolled into an omnibus franchise tax bill, House Bill 500, is relief that will help physicians provide vaccinations by allowing them to deduct from their taxable revenues the cost of purchasing and stocking vaccines. The legislation also provides tax breaks to small businesses, which includes many physician practices, and TMA worked to preserve existing physician exemptions related to Medicaid, Medicare, CHIP, Workers' Compensation, and other government payers. TMA backed HB 3169, which helped reverse an interpretation by the state comptroller that made it difficult to determine the taxable status of certain common medical supplies physicians purchase.

Senate Bill 63 by Senator Nelson and Rep. J.D. Sheffield, DO (R-Gatesville), allows a minor who is pregnant or a parent to consent to his or her own immunizations. Senate Bill 64, by Senator Nelson and Representative Zerwas, requires licensed child care facilities to develop and implement an immunization policy for their employees to protect the children in their care from vaccine-preventable diseases.

The state budget also includes additional money to keep the state FITNESSGRAM program alive in schools and collect data to address the state's obesity epidemic.

While efforts aimed at a statewide smoking ban once again failed, Mr. Alexander says Texas did make progress in tobacco prevention. TMA-backed House Bill 3536 subjects tobacco companies that were not part of the 1998 national tobacco settlement to the same taxes on the sale of cigarettes and tobacco products that the larger companies pay. Those fees were meant to compensate states for future health care costs caused by tobacco use.

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.